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FEMALE MILITARY VETERANS
AND TRAUMATIC STRESS
Jessica Wolfe, PhD
National Center for PTSD and Boston VAMC
Tufts University School of Medicine
Despite increasing interest in women in the mili-
tary, the literature on female veterans and traumatic
stress is surprisingly limited. This situation appears
partly due to a lack of female veterans' public vis-
ibility and a corresponding failure to emphasize the
scientific study of women in general. As a result of
that climate, the earliest writings on female veterans
and traumatic stress are largely personal recollec-
tions or clinical descriptions, typically by women
who served in Vietnam. Today, as the scientific
study of life trauma accelerates, investigators are
increasingly conducting more empirical studies of
traumatic stress in female veterans and examining
in greater detail the spectrum of military stressors
that may put women at-risk for problems in read-
justment. This article reviews a number of the im-
portant papers on female veterans and traumatic
stress. As with any newly emerging scientific field,
some of the important writings on this topic are
found in books and unpublished dissertations (e.g.,
Salvatore). The review concludes by suggesting
some areas for future research.
Schnaier's (1986) dissertation was one of the ear-
liest and most comprehensive examinations of
women and war stress. Using 89 female Vietnam
theater veterans, Schnaier administered an exten-
sive questionnaire containing scales on exposure,
symptomatology, and readjustment. Although for-
mal diagnoses of PTSD were not made, the study
showed that as many as 50% of participants experi-
enced symptoms suggestive of PTSD, with at least
20% of the respondents feeling that symptoms were
significantly disruptive. This study represented one
of the first efforts to systematically identify and
delineate traumatic war stressors in women, evalu-
ating, for example, the experiences and effects of
activities such as handling deaths and mutilations.
Shortly after, Paul (1985) developed a questionnaire
to investigate female veterans' distinctive war-time
stressors and was able to identify a series of both
event (i.e., war-zone) and personal (i.e., demo-
graphic) characteristics that, at least on a descrip-
tive basis, were associated with poorer post-war
adjustment in women Vietnam veterans including
military service at a younger age, less military and
professional experience, and occupational trauma
(e.g., extensive exposure to death and dying). These
factors were later confirmed by Baker et al. (1989).
Like the preceding studies, Norman's (1988) inter-
views of 50 American nurses who served in Vietnam
focused on the examination of outcome, stressor
characteristics, and individual factors, notably the
intensity of war-time stressors for noncombatants
and the negative effect of limited post-war supports
on subsequent adjustment. As with men, these ex-
periences were related to the continuation of higher
levels of intrusive andavoidant stress symptoms
although overall rates of symptomatology declined
over time.
The National Vietnam Veterans Readjustment
Study (NVVRS; Kulka et al., 1990) was the first
randomized, carefully controlled study to investi-
gate the prevalence of PTSD and associated disor-
ders in female theater veterans. This study had the
benefit of specially designed psychometric instru-
ments (e.g., the Mississippi Scale for Combat-Re-
lated PTSD) to corroborate interview data reflecting
the presence of stress symptoms. When this study
was completed, it essentially confirmed and ex-
tended prior descriptive studies on traumatic stress
in female veterans, showing that although female
Vietnam theater veterans had lower rates of PTSD
than male combatants, women clearly suffered from
the disorder in relation to the level of war-zone
exposure. Furey (1991) reviews this and the preced-
ing studies, and discusses some issues related to
PTSD assessment in female veterans.
Another source relates more directly to treatment
considerations including the effect of women's mi-
nority status within the military. Brende & Parson
(1985) provide a discussion of the clinical implica-
tions of both female veterans' stressors and the
adverse impact of minority status. Also included is
a theoretical discussion of the differential effects of
high and low magnitude stressors and the role of
personal meaning and attribution in mediating
women's adjustment to war stress. A number of
treatment suggestions are made for dealing with
issues of uniqueness, caretaking, and secrecy.
Rothblum and Cole (1986) have edited an unusual
compendium of writings by authors from a variety
Dr. Wolfe is the Acting Director of the Women's
Health Sciences Division of the National Center
for PTSD at the Boston VAMC. This Division
has pioneered research on the psychological
impact of military service on female veterans.
Such initiatives include development of psy-
chological and psychophysiological assessment
techniques, large scale surveys of female Viet-
nam veterans, and Operation Desert Storm re-
turnees. There has been a special emphasis on
the impact of sexual assault and on the effect of
PTSD on women's physical health.
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of mental health orientations. The collection contains analy-
ses on the traumatic exposure and painful psychological
recovery of a female Vietnam theater veteran. A primary
utility is their presentation of the need for a variety of
treatment conceptualizations and approaches in dealing
with traumatic stress in women. The importance of clini-
cians' appreciation for the impact of social mores on
women's expression of traumatic experiences and the pro-
pensity for silence and maintenance of caretaking roles is
also emphasized. The paper by Resick (1986) in this collec-
tion clearly describes the theory and practice of cognitive
behavioral treatment of PTSD.
More recent empirical studies have focused on topics
such as vocational readjustment, symptom expression (in-
cluding suppression and intensification), and coping. In a
distinctive study of the effects of women's active duty
status on stress symptomatology, Stretch et al. (1985)
showed that, despite clear-cut exposure, female active
duty personnel had significantly less PTSD than their
discharged veteran cohorts, suggesting that social support
functioned as a substantial moderator of initial PTSD. Leon
et al. (1990) studied coping patterns in female Vietnam and
Vietnam-era veterans and found that despite greater psy-
chological and interpersonal problems in the Vietnam
theater women, coping that entailed more self-blame and
a focus on negative affect and cognitions was significantly
associated with poorer outcome, irrespective of war-time
status. Besides providing the first empirical study of the
process of coping and its effects in female veterans, the
study offers preliminary data on the existence of military
stressors among era females, a topic sometimes overlooked
in the delineation of war trauma. In the first article on
homeless female veterans, Leda et al. (1992) describe a
small (1.6%) but noteworthy female subset of the current
homeless veteran population. These women are likely to
be younger, have lower rates of employment, and suffer
from more serious mental illness (particularly mood disor-
ders) than comparable males. Although rates of PTSD
were not substantial, more comprehensive evaluation of
diagnostic status is indicated. Finally, commensurate with
the PTSD literature in male veterans, studies of female
veterans now suggest a vulnerability for symptom intensi-
fication in women with prior war-time exposure. Wolfe et
al. (1990) used PTSD-validated psychometric tests to ex-
amine the reactions of female Vietnam veterans to the
onset of the Persian Gulf War. The authors found that
many of these veterans experienced clinically significant
intensification of stress symptoms following the start of the
war, with the greatest symptom increases seen in individu-
als with previously documented PTSD.
Systematic studies of women's military and war-time
exposure (rather than stress reactions) are still lacking.
Dienstfrey (1988) offers a broad-based review of combat
and war-zone exposure in female veterans across all eras,
with the interesting finding that when traditional exposure
parameters are used, World War II female veterans demonstrate the highest rates of combat exposure. A more
recent paper by Wolfe et al. (in press) presents the psychometric properties of a war-zone stressor scale for women
which was able to identify empirically a variety of significant stressors ranging from hazardous occupational tasks to sexual assault.
All of these studies demonstrate the importance of con-
tinuing further research into traumatic stress in female
veterans. Given the rates of victimization in our society,
future studies will certainly need to consider the network
of events encountered by female veterans and their poten-
tial additive or interactive effect across the life span.
SELECTED ABSTRACTS
BAKER, R.R., MENARD, S.W. & JOHNS, L.A. (1989). The
military nurse experience in Vietnam: Stress and impact. Jour-
nal of Clinical Psychology, 45, 736-744. Demographic, health, and
psychosocial data from two studies are presented on military
nurses assigned to Vietnam. Army nurse subjects in the first
study were grouped for comparison on three major variables:
assignment to Vietnam before versus after the 1968 TET Offen-
sive, type of nursing duties performed, and years of experience
as a registered nurse (RN) prior to assignment in Vietnam. The
second study compared another group of Army nurses with a
group of Air Force and Navy nurses also assigned to Vietnam.
Army nurses with less than two years RN experience prior to
their assignment were found to be more at risk for such negative
outcomes as difficulty establishing personal relationships and
difficulty coping with stressful situations. Stress experiences,
career dissatisfaction data, and health problems of military nurses
and their children are reported. Also described are positive
experiences of nurses in developing personal relationships in a
rewarding professional environment.
BRENDE, J.O. & PARSON, E.R. (1985). Special veteran groups:
Women and the ethnic minorities. In J.O. Brende & E.R. Parson
(Eds.), Vietnam veterans: The road to recovery (pp. 125-165). New
York: Plenum Press. Women and the ethnic minorities represent
special populations of Americans who served in Southeast Asia
during the Vietnam era. We refer to these groups as "special"
because of the uniqueness of their readjustment needs, which
have significant gender role and cultural elements. This unique-
ness is based, essentially, on their marginal status in American
society. Both female and ethnic minority veterans have had
experiences in the military that differ in fundamental, qualitative
ways from those of white male veterans.
DIENSTFREY, S.J. (1988). Women veterans' exposure to com-
bat. Armed Forces and Society, 14, 549-558. Women veterans who
were exposed to combat during their service were primarily
Army nurses who served during World War II. Additional
information presented is consistent with this conclusion. For
example, those who were exposed to combat have a higher rate
of post-secondary education and are more likely to be officers.
Rates of combat exposure increase with age for each wartime
period of service. The history of minority women in the military,
and the career choices available to them prior to and during
World War II, explains their relatively low rate of combat expo-
sure. Like men, more women were exposed to combat in World
War II than during either the Korean conflict or the Vietnam era.
Other characteristics of women combat veterans - particularly
higher postsecondary education, increased age, and a lower
proportion of minority participants than noncombat-exposed
female counterparts - stand in diametric contrast to what is
perceived about men who have been exposed to combat.
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PTSD RESEARCH QUARTERLY
FUREY, J.A. (1991). Women Vietnam veterans: A comparison
of studies. Journal of Psychosocial Nursing and Mental Health Ser-
vices, 29, 11-13. There is strong evidence that many women
exposed to war stress have suffered mental health problems
related to their experience, and a substantial number continue to
have serious emotional, psychosocial, and other readjustment
problems that affect their current level of functioning and life
satisfaction. The consistent exposure to severe combat casualties,
death and dying, workload extremes, personal deprivation, loss,
and danger all take a significant emotional toll. These studies
underscore the need for affected women to explore their war
experiences and associated feelings with mental health profes-
sionals, as well as the need for those professionals to develop an
awareness and understanding of the impact of specific war-
related stress on women.
KULKA, R.A., SCHLENGER, W.E., FAIRBANK, J.A., HOUGH,
R.L., JORDAN, B.K., MARMAR, C.R. & WEISS, D.S. (1990).
Trauma and the Vietnam War Generation: Report of findings
from the National Vietnam Veterans Readjustment Study.
New York: Brunner/Mazel. Abstracted in PTSD Research Quar-
terly, 1(3), 1990.
LEDA, C., ROSENHECK, R. & GALLUP, P. (1992). Mental
illness among homeless female veterans. Hospital and Commu-
nity Psychiatry, 43, 1026-1028. This study examined
sociodemographic and psychiatric diagnostic data from 19,313
veterans seen in the Department of Veterans Affairs Homeless
Chronically Mental Ill (HCMI) Veterans Program from 1988 to
1991. It does not appear that women are disproportionately
represented in the HCMI veterans program. Compared with the
male group, a significantly larger proportion of homeless female
veterans were diagnosed as having major psychiatric disorders,
and a significantly smaller proportion had substance use diag-
noses. The homeless women in our study appeared to be diagnos-
tically similar to homeless female nonveterans. [Adapted from
Text]
LEON, G.R., BEN-PORATH, Y.S. & HJEMBOE, S. (1990). Cop-
ing patterns and current functioning in a group of Vietnam and
Vietnam-era nurses. Journal of Social and Clinical Psychology, 9,
334-353. A group of 36 nurses who served in Vietnam were
compared with a group of 32 Vietnam-era military nurses on
patterns of coping during their duty tours, the impact of their
experiences, and current functioning. Coping patterns related to
expressing feelings, seeking emotional support, and searching
for meaning in the events experienced were associated with good
present psychological functioning. The use of self-blame, with-
drawal, and anxious thoughts as means of coping was related to
current psychological dysfunction. There was a trend for a greater
proportion of the Vietnam group to report continuing emotional
and relationship problems later than one year after Vietnam
service.
NORMAN, E.M. (1988). Post-traumatic stress disorder in
military nurses who served in Vietnam during the war years
1965-1973. Military Medicine, 153, 238-242. Fifty nurses who served
in Vietnam in the military were interviewed about their war
experiences and the presence of PTSD. Results indicate that the
number of nurses suffering from this disorder has decreased
since the initial post-war years. Two variables: The intensity of
the wartime experience, and supportive social networks after the
war, influenced the level of PTSD.
PAUL, E.A. (1985). Wounded healers: A summary of the
Vietnam Nurse Veteran Project. Military Medicine, 150, 571-576.
The Vietnam Nurse Veteran Project was designed to identify
stressors and after-effects experienced by nurses from the
psychosocial milieu peculiar to the Vietnam War. The sample
included 137 nurse veterans who completed a 52-item question-
naire designed by the author and a co-Investigator. Content
analysis of the data identified eight specific stressors in the
nurses' environment in Vietnam, such as: The young age and
severity of the casualties, danger to the nurses' lives, sexual
harassment, and survival guilt. Fourteen adverse after-effects
were identified and affected more than one-third (39%) of the
respondents. Some of the after-effects included: Nightmares,
flashbacks, career problems, and physical or emotional prob-
lems. This study reveals that nurses, like combat veterans have
suffered adverse after-effects from the Vietnam War, although
the stressors of the war, for the nurses, were markedly different.
RESICK, P.A. (1986). Post-traumatic stress disorder in a Viet-
nam nurse: Behavioral analysis of a case study. In E.D. Rothblum
& E. Cole (Eds.), A woman's recovery from the trauma of war: Twelve
responses from feminist therapists and activists (pp. 55-65). New
York: Haworth Press. (See below).
ROTHBLUM, E.D. & COLE, E. (1986). A woman's recovery
from the trauma of war: Twelve responses from feminist thera-
pists and activists. New York: Haworth Press (Also published as
Women & Therapy, Volume 5, Number 1, Spring 1986). Contains
twelve discussions of the case of "Ruth," a 39-year-old woman
who served as a Navy nurse in Vietnam and was referred to a
psychologist in private practice by a Veterans Administration
Alcoholism Treatment Program. [Adapted from Text]
SALVATORE, M. (1992). Women after war: Vietnam experi-
ences and posttraumatic stress: Contributions to social adjust-
ment problems of Red Cross workers and military nurses.
Unpublished doctoral dissertation, Simmons College School of
Social Work, Boston. This study described the unique experi-
ences and reactions of Red Cross workers and military nurses,
exploring in particular the relationships between Vietnam expe-
riences and PTSD symptoms and PTSD symptoms and later
adjustment problems. The sample (n = 335) of 233 Red Cross
workers and 102 military nurses responded to a mailed question-
naire. Measures for Vietnam experiences, PTSD symptoms, and
demographic data were developed for this study. The CES-D
scale for depressive symptoms and the Social Adjustment Scale
were also utilized. Both groups suffered PTSD symptoms with
nurses showing more short-term effects and more frequent night-
mares and alcohol problems. In 1987 a third of the group reported
depressive symptoms, PTSD symptoms, and vulnerability to
social adjustment problems. PTSD symptoms contributed to
social adjustment difficulties with mates, children, families, friends
and work. [Abridged Abstract].
SCHNAIER, J.A. (1985). A study of women Vietnam veterans
and their mental health adjustment. In C.R. Figley (Ed.), Trauma
and its wake. Vol. II: Traumatic stress theory, research, and intervention
(pp. 97-132). New York: Brunner/Mazel. Using a modified ver-
sion of Wilson and Krauss's (1981) Vietnam-Era Stress Inventory,
Schnaier studied 86 women veterans (primarily nurses attached
to medical facilities located in Vietnam) to assess the nature and
extent of the mental health problems affecting female veterans
and if their traumatic stressors were similar to male veterans
experiencing symptoms of PTSD. The author reported a signifi-
cant correlation between the stressors identified and symptoms
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associated with PTSD. The research revealed, among other things,
evidence of current mental health distress among female veter-
ans; personal and professional growth associated with war ser-
vice; and significant differences with regard to biographic/de-
mographic factors between male and female veterans. According
to Schnaier, this latter finding emphasizes the need for further
investigation of the female veteran population. She concludes the
chapter with a discussion of the implications of the findings for
treating women Vietnam veterans.
STRETCH, R.H., VAIL, J.D. & MALONEY, J.P. (1985). Post-
traumatic stress disorder among Army Nurse Corps Vietnam
veterans. Journal of Consulting and Clinical Psychology, 53, 704-708.
Results are presented from an epidemiologic investigation of
PTSD among Army nurse veterans [Vietnam Era Nurses Adjust-
ment Survey]. Analysis of questionnaire data from more than 700
Vietnam and Vietnam-era veterans still on active duty in the U.S.
Army Nurse Corps reveals a current PTSD rate for Vietnam
veteran nurses of 3.3%. This rate is comparable to that found
among nonnurse active duty Army Vietnam veterans (5.1%) and
is much lower than estimates (18%-54%) for civilian Vietnam
veterans. Results suggest that danger and exposure to violence
may be responsible for stress reactions such as PTSD among
noncombatants. Additional results indicate that social support is
an important moderator in the attenuation of PTSD.
WOLFE, J., BROWN, P.J. & BUCSELA, M.L. (1992). Symptom
responses of female Vietnam veterans to Operation Desert
Storm. American Journal of Psychiatry, 149, 676-679. Objective: This
study examined the status of symptoms of PTSD in a cohort of
women after the onset of Operation Desert Storm. Method:
Seventy-six non-treatment-seeking Vietnam veterans were ob-
tained from lists of those who recently had participated in other
research projects conducted at the National Center for Post-
Traumatic Stress Disorder. Before the onset of Operation Desert
Storm, subjects had completed a set of psychometrically valid
instruments measuring general psychological symptoms and
PTSD symptoms (e.g., SCL-90-R, Mississippi Scale for Combat-
Related Posttraumatic Stress Disorder). On the basis of the latter
scale, subjects were divided into groups with and without PTSD
symptoms. At the height of the military conflict, subjects were
recontacted and asked to complete the SCL-90-R and the Veterans
Update Form, a measure assessing changes in PTSD symptoms.
Results: Multivariate analyses indicated that while most female
Vietnam veterans experienced some intensification of stress-
related symptoms during Operation Desert Storm, those who
had previously reported high levels of PTSD were significantly
more susceptible to greater distress. Conclusions: Results of this
survey indicate that female Vietnam veterans with prior wartime
exposure are an at-risk population for the intensification of stress
symptoms after the recurrence of a military conflict.
WOLFE, J., BROWN, P.J., FUREY, J. & LEVIN, K.B. (in press).
Development of a War-Time Stressor Scale for Women. Psycho-
logical Assessment: A Journal of Consulting and Clinical Psychology.
Prior research has demonstrated the importance of stressor mea-
surement as a component of evaluating PTSD. Much of the work
conducted in this area has focused on male combat veterans,
resulting in the development of several combat exposure scales.
The nature of war-zone exposure for women, however, has not
been systematically addressed. This paper describes the develop-
ment and preliminary psychometric analyses of the Women's
War-Time Stressor Scale (WWSS) - an instrument designed to
measure the self-report of war-time stressors by both theater and
era veterans as well as civilian women who served in Vietnam.
Measurement of internal consistency, test-retest reliability, and
construct validity points to the potential clinical and research
utility of this type of instrument.
SLEEP DISTURBANCE IN POST-
TRAUMATIC STRESS DISORDER
Steven H. Woodward, PhD
National Center for PTSD and Palo Alto VAMC
This section of the PTSD Research Quarterly is devoted to
the symptom most commonly reported by survivors of
trauma, sleep disturbance. Notwithstanding the promi-
nence of nightmares and impaired sleep initiation/main-
tenance in PTSD, the literature addressing them is small,
major currents have yet to coalesce, and instances where
one study has built upon another are rare. The study of
sleep disturbance in PTSD is embedded, however, in an
active network of disciplines concerned with such diverse
topics as chronobiology, brainstem modulation of behav-
ioral state, and cognitive treatment of nightmares. The
following bibliography reflects some of this diversity.
Nightmares. Preeminent among topics within the field of
sleep in PTSD is that of nightmares. A question of particu-
lar concern to researchers is whether PTSD-related night-
mares arise out of REM sleep, NREM sleep, or both (Ross
et al., 1989). Since baseline physiological parameters, and
especially their dynamics, vary considerably across sleep
states, preferential emergence of PTSD nightmares from
one or the other could be informative. Contributing to
continued uncertainty in this regard, however, is the in-
triguing fact that nightmares occur only rarely in the sleep
laboratory (Hartmann, 1984). Nevertheless, sketchy direct
and indirect data bearing on this question can be found
(Kramer et al., 1984; Lavie et al., 1979; Ross et al., 1990; van
der Kolk et al., 1984; Woodward et al., 1991a,b).
A closely related (some would say, equivalent) question
is whether PTSD nightmares more closely resemble epi-
sodes of dream anxiety (definitionally REM-based), or
night terrors (also termed pavor nocturnus, a slow wave
sleep phenomenon observed principally in children). Fisher
et al. (1970) have provided vivid descriptions of adult night
terror and REM nightmare episodes with accompanying
psychophysiology in normals. Also pertinent is the dis-
tinction between acquired PTSD nightmare disturbance
and "lifelong" dream anxiety (see van der Kolk et al., 1984).
Continuities have been examined between PTSD night-
mares and nocturnal panic attacks (Hauri et al., 1989; see
also Mellman & Uhde, 1989a,b), and REM behavior disor-
der (Ross et al., 1990). Finally, Kaminer and Lavie (1991)
have reported dramatically reduced dream recall associ-
ated with successful post-trauma adjustment in a sample
of Holocaust survivors.
Beyond Nightmares. To date, sleep researchers in PTSD
have focused on features of sleep architecture which have
dominated the existing literature on sleep and psychopa-
thology, REM latency and slow wave sleep. Regarding
both, the PTSD sleep literature is self-contradictory. The
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latency of REM sleep in PTSD has been reported to be both
reduced (Greenberg et al., 1972; Kauffman et al., 1987), and
increased (Glaubman et al., 1990; Hefez et al., 1987; Lavie
et al., 1979). Slow wave sleep has been reported to be
reduced (Glaubman et al., 1990; Kramer et al., 1984), in-
creased (Dagan et al., 1991), and normal (Hefez et al., 1987;
Lavie et al., 1979). Interestingly, both cholinergic (Hobson
& Steriade, 1986) and noradrenergic (Siegel & Rogawski,
1988) perspectives on REM sleep would seem to converge
on a prediction that REM `pressure' would be increased
and REM latency reduced in PTSD.
Other currents in basic sleep research may prove impor-
tant to the study of sleep in PTSD. One such area is the
study of cognitive activity during sleep. Normals can
respond to auditory stimuli from all stages of sleep with
little modification of sleep architecture. Frequent anec-
dotal reports from combat-related PTSD patients suggest
continuous heightened awareness of the sleeping environ-
ment and hair-trigger arousability. Interestingly, there is
evidence that combat veterans with PTSD have elevated
arousal thresholds under certain conditions (Dagan et al.,
1991; Schoen et al., 1984).
Treatment Studies. Though there is empirical support for
common notion that sleep loss results in performance
failures, and reason to suspect that motor vehicle accidents
have caused a disproportionate number of deaths in Viet-
nam combat veterans (CDC, 1987), causative links have yet
to be established between sleep disturbance and accidents,
medical disease, and/or dysfunction in PTSD patients.
Nevertheless, patients' dysphoria associated with sleep
complaints (Inman et al., 1990) has motivated efforts to
treat sleep loss in this group. The small literature con-
cerned with the treatment of sleep disturbances in PTSD
has focused almost exclusively upon the reduction of
traumatic nightmare frequency, and consists largely of
single-case studies employing systematic desensitization
or imaginal flooding. The study of Cooper and Clum (1989)
represents a significant methodological advance in this
area. Controlled studies of therapeutic agents for PTSD
sleep disturbance have yet to be performed. Nevertheless,
the reader may be interested in two brief multiple-case
reports using imipramine (Marshall, 1975) and
cyproheptadine (Brophy, 1991).
In conclusion, research on sleep disturbance in PTSD
stands to benefit from the addition of new methods, larger
well-defined subject groups, and liberal exploration of
domains outside the current mainstream of sleep in psy-
chopathology.
SELECTED ABSTRACTS
COOPER, N.A. & CLUM, G.A. (1989). Imaginal flooding as a
supplementary treatment for PTSD in combat veterans: A con-
trolled study. Behavior Therapy, 20, 381-391. The present study
examined the incremental effectiveness of imaginal flooding (IF)
over standard psychotherapeutic and pharmacologic approaches
in the treatment of combat-related PTSD. Evidence was found
supportive of IF's effectiveness with regard to self-report symp-
toms directly related to the traumatic event(s), state anxiety,
subjective anxiety in response to traumatic stimuli, and sleep
disturbance. Flooding had no effect on level of depression or trait
anxiety, indicating that it is a useful adjunctive treatment for
PTSD but cannot likely be used as the sole vehicle of change.
DAGAN, Y., LAVIE, P. & BLEICH, A. (1991). Elevated awak-
ening thresholds in sleep stage 3-4 in war-related post-trau-
matic stress disorder. Biological Psychiatry, 30, 618-622. Awaken-
ing thresholds from sleep stage 3/4 were investigated in 19 DSM-
III-defined, war-related PTSD patients compared with 6 normal
controls. Patients had significantly higher awakening thresholds
and significantly longer latencies to an arousal response than
controls. These results are interpreted to suggest modifications in
the depth of sleep as one of the long-term sequelae of traumatic
events.
GLAUBMAN, H., MIKULINCER, M., PORAT, A.,
WASSERMAN, O. & BIRGER, M. (1990). Sleep of chronic post-
traumatic patients. Journal of Traumatic Stress, 3, 255-263. The
purpose of the present study was to investigate the sleep of people
diagnosed as suffering from chronic PTSD. The sleep of seven
chronic post-traumatic patients with no known physical injuries
was compared with that of seven matched control subjects. The
post-traumatic patients had poorer sleep: decreased sleep effi-
ciency, increase in number of awakenings, and decreased SWS, as
well as longer REM latency. It was also found that their com-
plaints correlated with relevant sleep-monitored measures.
GREENBERG, R., PEARLMAN, C.A. & GAMPEL, D. (1972).
War neuroses and the adaptive function of REM sleep. British
Journal of Medical Psychology, 45, 27-33. This study deals with the
relationship between the psychological state of a number of
patients with war neuroses and the development of REM sleep.
Beginning with the hypothesis that REM sleep is involved in the
process of handling and integrating stressful experiences, we
developed a method of assessing a patient's psychological state at
the time of the sleep study in order to correlate psychological state
with sleep recordings. Using our approach, we have been able to
demonstrate a clear relationship between specific psychodynamic
events in a patient and the physiological concomitants of dream-
ing, most striking in relation to pressure to dream as measured by
REM latency. [Adapted from Text]
HEFEZ, A., METZ, L. & LAVIE, P. (1987). Long-term effects of
extreme situational stress on sleep and dreaming. American
Journal of Psychiatry, 144, 344-347. Sleep data were obtained on 11
patients who had survived traumatic events and who complained
of sleep disturbances. Each was awakened from REM and non-
REM sleep for dream recall. The patients had lower sleep effi-
ciency indices (because of prolonged sleep latency and larger
amounts of "awake" plus "movement" time within sleep peri-
ods), shorter REM time, and longer REM latencies than did
control subjects. Four of the 11 patients had REM- and non-REM-
related nightmares, which, in two sea disaster patients, were
associated with REM-related motor activity. The rest of the pa-
tients had unusually low dream recall in spite of high eye move-
ment density.
BROPHY, M.H. (1991). Cyproheptadine for combat night-
mares in post-traumatic stress disorder and dream anxiety
disorder. Military Medicine, 156, 100-101. Pharmacologic treat-
ment of patients with PTSD often involves antidepressant drugs.
Combat nightmares often persist. The addition of cyproheptadine,
in a median dose of 16-24 mg orally at night, controls the night-
mares.
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LAVIE, P., HEFEZ, A., HALPERIN, G. & ENOCH, D. (1979).
Long-term effects of traumatic war-related events on sleep.
American Journal of Psychiatry, 136, 175-178. 11 patients who had
combat neuroses resulting from the 1973 Yom Kippur War and
complained of sleep disturbances were studied in a sleep labora-
tory. Sleep-onset insomniacs, dream-interruption insomniacs,
and pseudoinsomniacs were differentiated on the basis of
electrophysiologic recordings. Compared with normal controls
who actively participated in the Yom Kippur War, patients
showed significantly longer sleep latencies, lower sleep effi-
ciency indices, lower percentage of REM sleep, and longer REM
latencies.
MARSHALL, J.R. (1975). The treatment of night terrors asso-
ciated with the posttraumatic syndrome. American Journal of
Psychiatry, 132, 293-295. The author describes three cases in which
the frequency and intensity of night terrors associated with the
posttraumatic syndrome were greatly lessened by administra-
tion of imipramine; in one case, the night terrors disappeared
completely. Possible explanation for this effect of imipramine are
discussed, including the drug's arousal-preventing action. The
author believes that the study of sleep EEGs of patients suffering
posttraumatic syndrome will prove fruitful.
ROSS, R.J., BALL, W.A., DINGES, D.F., MULVANEY, F.D.,
KRIBBS, N.R., MORRISON, A.R. & SILVER, S.M. Motor activa-
tion during REM sleep in posttraumatic stress disorder. Sleep
Research 1990, 19, 175. While most studies find excessive move-
ment in the sleep of PTSD patients, especially during nightmares,
REM sleep is normally associated with atonia. These investiga-
tors performed polysomnography, with special emphasis on
recording and quantification of leg EMG, on 11 PTSD patients
and 6 controls. The authors found that in PTSD patients 4.6% of
REM epochs included phasic EMG, while for controls, this figure
was only 1.3% (p<0.05). NREM periodic leg movements were also
more frequent in the PTSD patients (11 per hour vs. 1 per hour,
p<0.01). These findings were consistent with a generalized motor
dyscontrol syndrome. Its association with REM sleep or even
sleep, per se, remained equivocal. The authors went on to note,
however, the presence of periodic leg movements, in particular,
distinguished the PTSD patients from depressed patients, in
whom such movements have generally not been observed. [SHW]
ROSS, R.J., BALL, W.A., SULLIVAN, K.A. & CAROFF, S.N.
(1989). Sleep disturbance as the hallmark of posttraumatic
stress disorder. American Journal of Psychiatry, 146, 697-707. Cited
in PTSD Research Quarterly, 1(1), 1990.
SCHOEN, L., KRAMER, M. & KINNEY, L. (1984). Auditory
thresholds in the dream disturbed. Sleep Research, 13, 102. Stud-
ied 16 Vietnam combat veterans: 8 qualified as "dream dis-
turbed" by demonstrating lab nightmares (NREM>=REM); 8
qualified as controls by reporting no nightmare complaints. The
dream disturbed veterans were more responsive than controls to
supra-threshold stimuli during sleep. This finding held for respi-
ration and gross motor responses, not heart rate or chin EMG, and
reached significance only during NREM sleep. As in other arousal
studies thresholds were generally lower in REM and generally
lower later in the night; however, in apparent contradiction to this
finding, the dream disturbed veterans demonstrated signifi-
cantly elevated thresholds to arousal stimuli in an ascending limits
protocol. This held for both REM and NREM sleep but seemed
especially prominent in early REM. [SHW]
INMAN, D.J., SILVER, S.M. & DOGHRAMJI, K. (1990). Sleep
disturbance in post-traumatic stress disorder: A comparison
with non-PTSD insomnia. Journal of Traumatic Stress, 3, 429-437.
Sleep disturbances, including repetitive nightmares and insom-
nia, are central and long-lasting aspects of PTSD. This study
utilized a questionnaire to compare sleep disturbance in Vietnam
war combat veterans having PTSD with non-PTSD patients hav-
ing insomnia without other PTSD symptoms. The PTSD group
reported symptoms of anxiety, agitation, and concurrent body
movement, which were associated with insomnia. Nightmares of
this group were more repetitive and more disruptive of a return
to sleep than the non-PTSD insomnia group. The PTSD group
also reported more fatigue during daytime functioning and more
anxiety during waking hours than the non-PTSD insomnia group.
KAMINER, H. & LAVIE, P. (1991). Sleep and dreaming in
Holocaust survivors: Dramatic decrease in dream recall in well-
adjusted survivors. Journal of Nervous and Mental Disease, 179,
664-669. Sleep data were obtained on 12 well-adjusted and 11
less-adjusted Holocaust survivors and on 10 control subjects.
Each was also awakened from rapid eye movement sleep for
dream recall. The less-adjusted survivors had more prolonged
sleep latency than the well-adjusted and the control groups and
lower sleep efficiency than the control subjects. The well-adjusted
group had a significantly lower dream recall rate (33.7 percent)
than the less-adjusted (50.5 percent) and control groups (80
percent). There were also significant between-groups differences
in dream structure and dream content, in the direction of less
complex and less salient dreams in the well-adjusted survivors. It
is suggested that the decrease in dream recall is one of the forms
of long-term adjustment to severe traumatic events.
KAUFFMAN, C.D., REIST, C., DJENDEREDJIAN, A., NELSON,
J.N. & HAIER, R.J. (1987). Biological markers of affective disor-
ders and post-traumatic stress disorder: A pilot study with
desipramine. Journal of Clinical Psychiatry, 48, 366-367. Three
biological markers of affective disorders and response to
desipramine were used to study the relationship of PTSD to
affective illness. Blunted TRH response and decreased REM
latency in eight patients with PTSD occurred at frequencies
similar to those that have been found in patients with major
affective disorder. Pretreatment Hamilton Rating Scale for De-
pression and Beck Depression Inventory scale scores were el-
evated; scores after 4 weeks' treatment with desipramine re-
vealed significant (p < .05 and p < .005, respectively) improve-
ment. These findings support a link between PTSD and affective
illness.
KRAMER, M., SCHOEN, L.S. & KINNEY, L. (1984). The dream
experience in dream-disturbed Vietnam veterans. In B.A. van
der Kolk (Ed.), Post-traumatic stress disorder: Psychological and
biological sequelae (pp. 81-95). Washington, D.C.: American Psy-
chiatric Press. Compared Vietnam combat veterans with and
without nightmare complaints. Those without nightmares had to
endorse at least one other symptom of PTSD. Reduced REM
percent (18%) was observed in both groups. Content of mentation
was obtained from experimenter-initiated awakenings from REM
and NREM sleep. Nightmare sufferers included Vietnam-related
content in 47% of dream reports, while the comparable figure for
controls was only 4%. Within nightmare sufferers, Vietnam-
related content was not preferentially associated with REM vs.
NREM awakenings. [SHW]
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VAN DER KOLK, B.A., BLITZ, R., BURR, W.A., SHERRY, S. &
HARTMANN, E. (1984). Nightmares and trauma: A comparison
of nightmares after combat with lifelong nightmares in veter-
ans. American Journal of Psychiatry, 141, 187-190. In this study the
chronic traumatic nightmares of men who had been in combat
were found to differ from the lifelong nightmares of veterans
with no combat experience in that they tended to occur earlier in
the sleep cycle, were more likely to be replicas of actual events,
and were more commonly accompanied by gross body move-
ments. Traumatic nightmares may arise out of varying stages of
sleep and are not confined to REM sleep alone. The group with
lifelong nightmares showed evidence of thought disorder on the
Rorschach. The men with PTSD had failed to psychologically
integrate their traumatic experiences and used dissociation as a
way of dealing with strong affects.
WOODWARD, S.H., ARSENAULT, N., BLIWISE, D.L. &
GUSMAN, D.F. (1991a). Physical symptoms accompanying
dream reports in combat veterans. Sleep Research, 19, 153. Five
nights of self-report data consisting of awakening times, dream
types, and physical symptom(s), were collected from 18 Vietnam
combat veterans enrolled in a post-traumatic stress disorder
(PTSD) inpatient treatment program. Self-reports were made
when subjects awoke spontaneously and judged that they would
remain awake for some time. Sweating reports were associated
almost exclusively with awakenings on which Vietnam night-
mares were also reported. Tachycardia reports were associated
with awakenings including reports of all dream types; further-
more, in later sleep cycles, tachycardia reports were associated
with Vietnam and non-Vietnam nightmares at similar rates.
However, early in the night, tachycardia reports were specific to
awakenings including Vietnam nightmare reports. These data
are generally in accord with the established link between dream
content and physiologic arousal in normal volunteers.
WOODWARD, S.H., ARSENAULT, N., BLIWISE, D.L. &
GUSMAN, D.F. (1991b). The temporal distribution of combat
nightmares in Vietnam combat veterans. Sleep Research, 19, 152.
Five nights of self-report data consisting of awakening times,
dream types, and physical symptom(s), were collected from 18
Vietnam combat veterans enrolled in a post-traumatic stress
disorder (PTSD) inpatient treatment program. "Vietnam" night-
mares exhibited an increase in frequency early in the night. In
contrast, the distribution of non-Vietnam nightmares and pleas-
ant dreams appeared consistent with the normative distribution
of REM time. Expressed as a proportion of "normal" dreams, the
frequency of "Vietnam" nightmares decreased monotonically
after the initial burst. These data reinforce earlier suggestions that
the early sleep cycles deserve special attention in
polysomnographic studies of PTSD.
Selected References on Sleep and Sleep Problems
CENTERS FOR DISEASE CONTROL (1987). Postservice mor-
tality among Vietnam veterans. Journal of the American Medical
Association, 257, 790-795.
FISHER, C., BYRNE, J., EDWARDS, A. & KAHN, E. (1970). A
psychophysiological study of nightmares. Journal of the Ameri-
can Psychoanalytic Association, 18, 747-782.
HAURI, P., FRIEDMAN, M.J. & RAVARIS, C.L. (1989). Sleep
in patients with spontaneous panic attacks. Sleep, 12, 323-337.
HOBSON, J.A. & STERIADE, M. (1986). The neuronal basis of
behavioral state control. In V.B. Mountcastle & F.E. Bloom (Eds.),
Handbook of Physiology. Vol. IV. Bethesda, MD: American Physi-
ological Society.
MAGEE, J., HARSH, J. & BADIA, P. (1987). Effects of experi-
mentally-induced sleep fragmentation on sleep and sleepiness.
Psychophysiology, 24, 528-534.
MELLMAN, T.A. & UHDE, T.W. (1989a). Electroencephalo-
graphic sleep in panic disorder. A focus on sleep-related panic
attacks. Archives of General Psychiatry, 46, 178-184.
MELLMAN, T.A. & UHDE, T.W. (1989b). Sleep panic attacks:
New clinical findings and theoretical implications. American
Journal of Psychiatry, 146, 1204-1207.
SIEGEL, J.M. & ROGAWSKI, M.A. (1988). A function for REM
sleep: Regulation of noradrenergic receptor sensitivity. Brain
Research Reviews, 13, 213-233.
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PTSD RESEARCH AT THE ST. CLOUD VAMC
Charles G. Watson, PhD
The St. Cloud PTSD research program has concentrated
on the description of PTSD, its measurement, and its risk
factors.
Definition and Description of PTSD. PTSD research at St.
Cloud began in the early 1980s with efforts to identify the
symptoms of the disorder. In an early study, Melodie Van
Kampen and I examined the correlations of each DSM-III
PTSD symptom with eligibility for a PTSD diagnosis. Our
results suggested that the most characteristic symptoms of
PTSD are those dealing with reexperiencing of the trauma.
In contrast, some other items (e.g., survival guilt, concen-
tration problems) did not correlate significantly with eligi-
bility for PTSD diagnosis, suggesting that they might be
deleted from the diagnostic manual. In a second study, we
compared PTSD symptom self-ratings of patients report-
ing delayed and undelayed onsets. They did not differ,
which argued against categorizing delayed- and undelayed-
onset PTSD as separate subtypes, as had been done in
DSM-III. In a third study, Douglas Anderson and I factor
analyzed the DSM-III symptoms, hoping to determine
how they might best be categorized in future DSM edi-
tions. The findings (separate Intrusive Thoughts, Arousal,
Impoverished Relationships, Guilt, and Cognitive Inter-
ference factors) gave more support to the DSM-III-R sys-
tem than to earlier ones, but suggested additional changes
as well.
In a current study, Mark Juba and I are attempting to
identify the specific characteristics (e.g. baseline, length of
response, peak amplitude, acceleration and deceleration
rates, etc.) of the physiological hyperarousal found in
PTSD.
Psychometrics. Our primary effort in this area has been
the development of the Posttraumatic Stress Disorder In-
terview (PTSD-I). It consists of 17 7-point self-ratings closely
reflecting DSM-III-R standards. It generates both binary
present/absent and continuous severity outputs for each
symptom and for the entire disorder. It offers high test-
retest reliability, internal consistency, and validity.
We reviewed the empirical literature on the strengths
and weaknesses of 12 PTSD measures in a 1990 article.
Those with the most encouraging validities were our PTSD
Interview (PTSD-I), the Structured Clinical Interview for
DSM-III-R PTSD module, and Keane et al.'s Mississippi
Scale. In a subsequent comparative validation, we also
found the PTSD-I and Mississippi Scale offered better
validity than the Diagnostic Interview Schedule PTSD
module or the Keane et al. MMPI PTSD scale.
Risk Factors. The primary focus in our current research is
the identification of factors influencing risk for PTSD after
trauma exposure. Like other studies, our results suggest
that rebellious adolescent behavior, such as drinking and
conflict with authority, does not predict PTSD. Nor did
self-reports of childhood PTSD-like behaviors (such as
nightmares, social withdrawal, or easy startling) predict
later PTSD. Patricia Thienes-Hontos and I also found PTSD
symptoms reported with equal frequency in the files of
Vietnam veterans entering our hospital in the 1970s and in
those of Korean War patients treated here in the 1950s. This
suggested that the peculiar circumstances surrounding the
Vietnam War may not have contributed to PTSD risk,
contrary to popular folklore. Additionally, Rev. Gary Berg,
our Chaplain Service Chief, has produced evidence that
high moral development is associated with a dampening of
PTSD's symptoms after exposure to severe trauma. We
have also studied the effects of stresses which occur before
trauma on risk for PTSD in two studies. The results of the
first suggested that exposure to stress leads to a psycho-
logical "vaccination" which reduces the ability of a later
trauma to cause PTSD. However, our second study yielded
negative results and failed to confirm this finding.
In our current Merit Review program, Butch Nugent and
I are studying the relationship of PTSD to each of 45 other
disorders in a large help-seeking population. We are also
collecting data on the sequence in which trauma, PTSD,
and comorbid disorders develop. This may help identify
the effects that trauma, PTSD, and other conditions have on
one another.
Selected Bibliography
BERG, G.E., WATSON, C.G., NUGENT, B. & JUBA, M. (Sub-
mitted for publication). Comparison of combat's effects on PTSD
scores in high and low moral development veterans. St. Cloud,
VA Medical Center, 4801 8th Street N., St. Cloud, MN 56303.
THIENES-HONTOS, P., WATSON, C.G. & KUCALA, T. (1982).
Stress-disorder symptoms in Vietnam and Korean War veter-
ans. Journal of Consulting and Clinical Psychology, 50, 558-561.
VAN KAMPEN, M., WATSON, C.G., TILLESKJOR, C.,
KUCALA, T. & VASSAR, P. (1986). The definition of posttrau-
matic stress disorder in alcoholic Vietnam veterans: Are the
DSM-III criteria necessary and sufficient? Journal of Nervous and
Mental Disease, 174, 137-144.
WATSON, C.G. (1990). Psychometric posttraumatic stress dis-
order measurement techniques: A review. Psychological Assess-
ment: A Journal of Consulting and Clinical Psychology, 2, 460-469.
WATSON, C.G., JUBA, M.P., MANIFOLD, V., KUCALA, T. &
ANDERSON, P.E.D. (1991). The PTSD Interview: Rationale,
description, reliability and concurrent validity of a DSM-III-
based technique. Journal of Clinical Psychology, 47, 179-188.
WATSON, C.G., KUCALA, T., JUBA, M., MANIFOLD, V. &
ANDERSON, P.E.D. (1991). A factor analysis of the DSM-III
post-traumatic stress disorder criteria. Journal of Clinical Psychol-
ogy, 47, 205-214.
WATSON, C.G., KUCALA, T., MANIFOLD, V., JUBA, M. &
VASSAR, P. (1988). The relationships of post-traumatic stress
disorder to adolescent illegal activities, drinking, and employ-
ment. Journal of Clinical Psychology, 44, 592-598.
WATSON, C.G., KUCALA, T., MANIFOLD, V. & VASSAR, P.
(1989). Childhood stress disorder behaviors in veterans who do
and do not develop posttraumatic stress disorder. Journal of
Nervous and Mental Disease, 177, 92-95.
WATSON, C.G., PLEMEL, D., DEMOTTS, J., HOWARD, M.T.,
TUORILA, J., MOOG, R., THOMAS, D. & ANDERSON, D. (Sub-
mitted for publication). Comparison of four PTSD measures'
convergent validities in Vietnam veterans. St. Cloud, VA Medi-
cal Center, 4801 8th Street N., St. Cloud, MN 56303
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